Dissertations, On cynanche trachealis or croup, and On the functions of the extreme capillary vessels in health and disease : to which were awarded the Boylston premiums for the years 1820 and 1823 / by William Sweetser.

  • Sweetser, William, 1797-1875.
Date:
1823
    take place at any period of this stage from suffocation, when the child is carried off in violent struggles. Frequently before death the cough will wholly cease, the respiration also will seem to be performed with more ease, and without the peculiar sound which before accompanied it; but the livid paleness of the countenance, the small, frequent, fluttering pulse, and the coldness of the extremities, show us too plainly the fallaciousness of these symptoms. Sometimes in this stage of the disease, the child will be suddenly relieved, respiration will be performed with much comparative ease, and it is said that in some instances he even becomes playful, but on a sud- den the difficulty returns with increased severity, and he dies with every symptom of suffocation. This has been explained by supposing a portion of the false membrane to become detached, and after a certain time to be forced by the air into such a situation as, like a valve, to close up the air passage. It is stated by writers on the disease, that the stage of effusion does occasionally last for days, or even weeks, the patient every little while expectorating portions of the false membrane, and ultimately recov- ering. Sometimes through the whole disease, great insensibility to the action of medicines is witnessed. In the 29th vol. of the London Medical and Physical Journal, there is recorded a case, in which, in the space of forty eight hours, a boy of two years old took forty-nine grains of antimonial powder, and in less than three days, forty-seven grains of calomel, and the bowels were never opened more than twice any day
    during the disease, the salivary glands not at all affected, and the breath not in the least tainted. On the prognosis in croup little needs be said. If we see the patient in the first stage, there will be a pretty good chance of effecting a cure, and the earlier we are called to him in this stage, the greater will the probability be of our success. If the physician is not called in until the second stage, the cure becomes quite doubtful, and the longer it has continued, the smaller is the chance of success. There are instances, how- ever, recorded, where the disease had continued, so long as two days, and still a cure was effected, and apparently by resolution. We must be greatly influ- enced at any period, in forming our prognosis, by the severity of the symptoms. Though when effusion has taken place, we can scarcely hope for a recovery, yet, in some rare instan- ces, the effused matter, or false membrane, has been expectorated, and a perfect restoration to health fol- lowed. Some instances are recorded where the mem- brane was expectorated entire, but it has been oftener coughed up in small portions at a time. Recovery does by no means always follow its expectoration, for it is plain that when the disease is extensive, and the lungs much affected, this can do but little good. The disease too may have so exhausted the living powers, that even should the cause of the disorder be removed, its effects on the system could not be recovered from. Cheyne, in his Essay on the complaint under consid- eration, gives a case in which the membrane com- pletely formed, was coughed up twice, and still the child died. In this last stage, as well as through the
    whole course of the disease, we must be much gov- erned in forming our prognosis, by the respiration, pulse, and general powers of the patient. Diagnosis. In the first place we will attempt to point out the distinctive characters between croup and cynanche laryngea. It was not until very lately that a line of distinction was drawn between these two diseases ; the ancients probably described them both under that species of quinsy, sine apparente tumore. Boerhaave and his commentator both remark, that a quinsy from inflammation of the windpipe is attended with the greatest danger when the seat of it is espe- cially about the larynx and its muscles. In such cases, too, they also notice that there is great pain and diffi- culty during the act of deglutition, which symptom is not mentioned by them as occurring when the disease, in their belief, principally affects the trachea. Within a few years cynanche laryngea has excited in Europe a good deal of interest, much of which was at first owing to the circumstance of two distinguished physicians* having died of it at about the same period. Instances of it have also occurred in our own country, and the two first on record, in individuals whose names are intimately connected with the history of our country.f Late dissections have shown that the cynanche laryngea differs considerably from croup. Many of its symptoms, too, are different, as well as the subjects whom it attacks. * Dr David Pitcairn, and Sir John Macnamara Hayes, t George Washington and Samuel Dexter.
    Cynanche laryngea attacks, so far as observation has extended, only adults, and it has generally made its appearance in persons somewhat advanced in life. Cynanche trachealis attacks children only, or those under the age of puberty, and we have no well marked case on record of its occurrence in the adult. Both these affections appear to be produced by the same, or nearly the same exciting causes, and they are both attended with great danger to life. Many symptoms, too, are common to them both. Some have asserted that in cynanche laryngea there is pain felt in a small spot about the larynx, but that in croup there is rather a diffused sense of uneasi- ness, or the pain is more extensive. Little depen- dence, however, can be placed on this diagnostic mark, for in the former affection there is generally rather a sense of uneasiness about the larynx than acute pain, and in the latter, when there is pain in the affected parts, it is most usually referred to the larynx or its immediate neighbourhood. As in cynan- che laryngea the inflammation about the parts which are immediately concerned in forming the voice, is generally more severe than in croup, the disease being more concentrated in the larynx, we should infer, a priori, that the voice would be more uniformly, and in a greater degree affected. In some of the few cases recorded, we find it noticed that the patient was una- ble to raise his voice above a whisper, and in all that great pain accompanied efforts to articulate, so that the patient endeavoured to avoid speaking as much as possible.
    The sound of the respiration differs somewhat in this disease from that in croup ; nor is the breathing so difficult at its commencement, but it goes on increasing in difficulty, even with greater rapidity than in the last mentioned disease. In all the cases of cynanche laryngea which have been given to the pub- lic, difficulty of deglutition accompanied the other symptoms, owing to an inflammation and swelling of the fauces. Different morbid appearances are exhibited in these diseases after death. In cynanche laryngea, the fauces are somewhat inflamed and swollen. The uvula, and velum palati, are often found oedematous, and at times, the tonsils likewise. The upper and fore part of the pharynx are inflamed, and this inflammation is found extending on the mucous membrane common to these parts, to the epiglottis, glottis, upper part of the larynx, and sometimes, though with abated severity, to the trachea and bronchiae. It would seem that the inflammation commences in the pharynx, because difficulty of deglutition is noticed as one of the first symptoms, showing itself before the respiration be- comes manifestly affected. In those who have died of cynanche laryngea, serous effusion has generally been found in the cellular membrane behind the larynx, and also under the mucous membrane of the glottis and upper part of the larynx. The epiglottis, too, is occasionally oede- matous. Sometimes coagulable lymph is effused on the mucous membrane of the glottis. Now in croup, as may be seen by referring to its proximate cause, there is no disease of the fauces or pharynx, there is 4